ACKNOWLEDGMENT OF RISKS AND RELEASE OF LIABILITY

Participant's Full Name:

First Name Last Name

Age(in months): blanks DOB: blank

Parent Name:

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Parent Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

If you are not a parent of the participant, but are a court-appointed conservator or guardian, please complete the following:

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

***A copy of the court order must be provided. Please note that only a parent, conservator, or guardian can complete and sign this form

Does this child have any health and/or medical problems that we should be aware of?

Yes No

Please initial that you have fully communicated all health issues, medical problems, and/or conditions on the Student Interview Form to the ISR Registration Evaluation Team.

Explain all health issues, medical problems, and/or conditions:

blanks

I,

First Name Last Name

the
parent/conservator/guardian of the enrolled participant agree and understand that swimming is a
hazardous activity. I recognize that there are inherent risks in the sport of swimming, including
but not limited to paralyzing injuries and death. In case of accident or injury during ISR
swimming lessons, I authorize any representative of Columbus Swimming Resource, LLC
(Lauren Haza) to have the participant treated for said accident or injury. Further, I agree to pay
all costs associated with the transportation and medical care for the enrolled participant. Except
when directly and primarily caused by the negligence of Columbus Swimming Resource, LLC, I
agree to indemnify and hold harmless Columbus Swimming Resource, LLC and all its
representatives with regard to all damages and/or expenses incurred, including legal fees, which
relate to any accident or injury that may occur to the participant while in ISR swimming lessons,
or while on the property at 3936 25th Street, Columbus, IN or any other facility in which
Columbus Swimming Resource (Lauren Haza) teaches lessons. I also agree to indemnify
Columbus Swimming Resource, LLC and all its representatives for any damages and/or
expenses, including legal fees, incurred by Columbus Swimming Resource, LLC, which arise
from any other claims, demand, action, or cause of action related to the participant’s enrollment
in the program. Disclosure of ALL health issues, medical problems, and/or conditions is critical
to the child’s safety and well being during lessons. I understand and agree that Columbus
Swimming Resource, LLC will not be responsible for any accident or injury that could have
resulted in any way from a failure to make full disclosure. I agree to be solely responsible for the
care of my child before and after lessons and while out of the water. I agree to be solely
responsible also for the care of any other children I have brought to the pool with me. I
understand that running on the pool deck is not allowed at any time and I must control all
children under my care. I understand that there is no such thing as “drown-proofing” a child. I
agree to supervise my child/children when in or around water even if the full course of lessons is
successfully completed. I understand that failure to successfully complete the full course of
lessons will result in little or no water protection for the participant and that I must supervise my
child/children when in or around water. I, ON BEHALF OF MYSELF AND THE
PARTICIPANT(S) AND OTHER CHILDREN UNDER MY CARE, HAVE CAREFULLY
READ THIS FORM AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT
THIS INCLUDES A RELEASE OF LIABILITY AND SIGN IT OF MY OWN FREE WILL
ON BEHALF OF THE PARTICIPANT(S) AND OTHER CHILDREN UNDER MY CARE.

Name

First Name Last Name

Date

Signature

Clear